15.2 Major burn wounds

Type of Infection	First Line (with Dosage and Duration)	Alternative First Line (with dosage and Duration)	Comments
Second- degree burns	For wound care: Silver sulfadiazine 1% water-soluble cream, is a combination of sulfadiazine and silver with antimicrobial efficacy lasting up to 24 hours. Silver nitrate (0.5% aqueous) is applied with occlusive dressings but does not penetrate eschar and it depletes electrolytes, and stains the local environment, broad spectrum, may cause methemoglobinemia Mafenide acetate, available both as an 8.5% water-soluble cream and a 5% aqueous solution, is among the most commonly employed topical agents. The cream is applied twice a day and has the advantage that it does not require a dressing to adhere to wounds. Mafenide has excellent tissue penetration, including eschar. Systemic antimicrobial therapy is only indicated for patients with proven burn wound infection or sepsis (culture proven).		Burn treatment varies depending on the cause and severity. All burns should be kept clean and proper bandages/dressing should be applied, depending on the severity of the wounds. Treating the patient’s pain is key: inadequate control can interfere with wound care.
Third- degree burns: It can be life- threatening		Mupirocin is a topical treatment of choice for MRSA infections, Gram- positive microbes, and intranasal carriage, inhibits wound healing by a half-life of 2 days, should not be used for longer than 10 days to prevent development of resistance	Excise adherent necrotic tissue initially and debride all necrotic tissue. Change the dressing daily (twice daily, if required) or as often as necessary to prevent seepage through the dressing or when the wounds are more exudative. Second degree deep burns are managed by Tangential excision and grafting preferably within 5- 7 days of sustaining burn injury. For full thickness burns, burn wound excision is done followed by coverage with autograft or allograft/ dermal substitutes when there is paucity of donor autograft. Tranexamic acid (TXA) can potentially reduce blood loss and transfusion requirements associated with burn surgery.

Type of Infection

First Line
(with Dosage and Duration)

Alternative First Line
(with dosage and Duration)

Comments

Second- degree burns

For wound care: Silver sulfadiazine 1% water-soluble cream, is a combination of sulfadiazine and silver with antimicrobial efficacy lasting up to 24 hours. Silver nitrate (0.5% aqueous) is applied with occlusive dressings but does not penetrate eschar and it depletes electrolytes, and stains the local environment, broad spectrum, may cause methemoglobinemia Mafenide acetate, available both as an 8.5% water-soluble cream and a 5% aqueous solution, is among the most commonly employed topical agents. The cream is applied twice a day and has the advantage that it does not require a dressing to adhere to wounds. Mafenide has excellent tissue penetration, including eschar. Systemic antimicrobial therapy is only indicated for patients with proven burn wound infection or sepsis (culture proven).

Burn treatment varies depending on the cause and severity. All burns should be kept clean and proper bandages/dressing should be applied, depending on the severity of the wounds. Treating the patient’s pain is key: inadequate control can interfere with wound care.

Third- degree burns: It can be life- threatening

Mupirocin is a topical

treatment of choice for MRSA infections, Gram- positive microbes, and

intranasal carriage, inhibits wound healing by a half-life of 2 days, should not be used for longer than 10 days to prevent development of resistance

Excise adherent necrotic tissue initially and debride all necrotic tissue.

Change the dressing daily (twice daily, if required) or as often as necessary to prevent seepage

through the dressing or when

the wounds are more exudative.

Second degree deep burns are managed by Tangential excision and grafting preferably within 5- 7 days of sustaining burn injury. For full thickness burns, burn wound excision is done followed by coverage with autograft or

allograft/ dermal substitutes when there is paucity of donor autograft.

Tranexamic acid (TXA) can potentially reduce blood loss and transfusion requirements associated with burn surgery.

For common etiological agents of Major burn wounds, see Annexure B.15.2

Additional Information

Second-degree burns: Affect epidermis and part of dermis. The patient may experience pain, redness, swelling and blistering. Second degree can again be classified as second degree superficial which involves epidermis and the papillary dermis and Second-degree deep burns which involves the deeper reticular dermis as well.
Third-degree burns: affect epidermis and dermis. The burn also destroys hair follicles and sweat glands. Because third-degree burns damage nerve endings, you probably won't feel pain in the area of the burn itself, rather adjacent to it. Burned skin may be black, white or brown with a leathery appearance.
Consider Lund & Browder's chart for burn wound estimation.
Burns greater than 20% surface area (adult), greater than 10% (child) or any burn occurring in the extremes of age are considered serious.
Management of major burns: Airways, oxygen inhalation, securing central venous line, adequate and proper Fluid Resuscitation, pain relief with analgesia and sedation, isolation of patient, NG Tube, foleys catheter & H2 receptor antagonists, Tetanus prophylaxis, Care of burn wound and operative management as necessary & other supportive measures etc.
Patient's energy and protein requirements will be extremely high due to the systemic hypermetabolic response with gluconeogenesis, insulin resistance and protein catabolism, heat loss, infection and demands of tissue regeneration. If necessary, feed the patient through a nasogastric tube to ensure an adequate energy intake (up to 6000 kcal a day). Consultation with dietician and nutritionist is necessary for each burn patient to ensure adequate calorie intake according to Curreri Formula:
- Adult- 25 kcal/Kg+ 40kcal X %TBSA
- Children- 60kcal/ Kg + 35 kcal X % TBSA
Gastroparesis is common, and prokinetic agents such as metoclopramide is helpful in promoting gastric emptying.
Protein and multivitamin supplements are indicated for these patients. Serum prealbumin levels are checked every 3 days to monitor nutritional status.
Anaemia and malnutrition prevent burn wound healing and result in failure of skin grafts.
Systemic antibiotics are generally in early post burn period.
Fever is not a useful sign of an infection, as it may persists due to burn per se.
Systemic antibiotics can be initiated in proven septicaemia or can be given empirically as per hospital antibiograms for suspected sepsis awaiting culture results.

References

1. Lu J, Yang M, Zhan M, Xu X, Yue J, Xu T. Antibiotics for treating infected burn wounds. Cochrane Database Syst Rev. 2017 Jul 3;2017(7):CD012084. doi: 10.1002/14651858.CD012084.pub2. PMCID: PMC6483291.

2. WHO, Burn Management. https://www.who.int/docs/default-source/integrated-health-services-%28ihs%29/csy/surgical-care/imeesc-toolkit/best-practice-safety-protocols/burn-management.pdf

3. Barajas-Nava LA, López-Alcalde J, Roqué i Figuls M, Solà I, Bonfill Cosp X. Antibiotic prophylaxis for preventing burn wound infection. Cochrane Database Syst Rev. 2013 Jun 6;2013(6):CD008738. doi: 10.1002/14651858.CD008738.pub2. PMID: 23740764; PMCID: PMC11303740.